Form of Application for Provisional Registration

To,
The Registrar,
Gujarat Medical Council,
Opp. Maniben Ayurvedic Hospital,
B/s. Civil Hospital Post Office,
AHMEDABAD-380 016.
Sir,
I request you to give the provisional registration under Section 25 of the Indian
Medical Council Act, 1956 and to issue the necessary certificate. My Particulars are stated
below:-

Name in Full:-
(Beginning with Surname and
including father’s/husband’s
name in block letters only)_____________________________________________________
Address____________________________________________________________________
_____________________________________________________________________
Maiden Name and Surname in the
Case of a married woman
(Beginning with Surname in
block letters).________________________________________________________________
Nationality__________________________________________________________________
Date of Birth________________________________________________________________

Qualification or examination passed______________________________________________

Name of University or Licensing Body___________________________________________

Institution from which appeared for the

Examination and Number at the Examination______________________________________
___________________________________________________________________________
Date of passing the Examination or of
Obtaining the qualification_____________________________________________________
2. I Forward herewith :-
(i) +My Birth Certificate
Matriculation Certificate OR
S.S.C. Examination Certificate OR
School Leaving Certificate in Original
and
(ii) +the Degree
Diploma
Certificate of passing the qualifying
Examination which I posses, in Original

These may be returned to me when no longer required.

3. I have been selected for :-

* practical training at the_____________________________________________________

(state name of approved institution)______________________________________________

___________________________________________________________________________
* employment in a medical capacity at the_________________________________________
_____________________________________________ (state name of Approved institution)
appointment in the medical Services of the Armed Forces of the Union: and I enclose as
evidence____________________________________________________________________

4. The registration fee is Rs.250/- which may be remitted

By cash or Demand Draft
By Money Order or
By Crossed Indian Postal Order

5. I am applying for registration for the first time and I was not registered as a medical
practitioner in India before the date of this application.

6. I have carefully read the instructions sent with this form and I certify that the
Particulars furnished above are true to the best of my knowledge and belief.

Yours Faithfully,
Date :_____________________

Place :_____________________ (Usual Signature)

INSTRUCTIONS

1. All Particulars shall be filled by the applicant only.

2. All particulars should be in legible hand.
3. The registration fee should be sent in person or by money order. When the fee is sent
by money order, the postal receipt should be attached with the application.
4. The applicant should remember that their names entered in the application must
exactly correspond with their names at the University or the Examination, as the case
may be.
5. Certificate from the Dean of the College regarding duration of Internship.
6. Attested copies of all the Original Certificates should be enclosed along with their
Originals, otherwise Original Certificates will be retained in the Office of the Council.
7. You are requested to remit Rs.100/- (Extra) if you desire to get your Provisional
Registration Certificate by Registered Post.
8. In case of remittance by Crossed postal Order, Rs.20/- extra will have to be sent to
meet bank charges for realization of the amount of the Indian Postal Order.
9. Evidence regarding change of Name/Surname be sent viz. Gazette Marriage
Registration Certificate, as the case may be.

* Strike off the alternative not applicable.